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MEDICAL

Plan Comparison Chart - 2009

Here is a comparison of your medical plan options. Not all associates will have access to a HMO.

Feature/Service	Buy-Up Plan		Basic Plan		Health Choice Savings Plan		Local HMO**
Feature/Service	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	Local HMO**
Outpatient Services
Primary Care Office Visit	$25	70% covered after deductible	$25	60% covered after deductible	100% covered after deductible	100% covered after deductible	100% covered after $25 co-pay
Specialty Visit	$35	70% covered after deductible	$35	60% covered after deductible	100% covered after deductible	100% covered after deductible	100% covered after $35 co-pay
Annual Physical (Routine Physical Exam - Adult, 16 years +)	100%	70% covered after deductible	100%	60% covered after deductible	100%	100% covered after deductible	100% covered after co-pay
Routine Mammogram (1/year)	100%	70% covered after deductible	100%	60% covered after deductible	100%	100% covered after deductible	100% covered after co-pay
Routine OB/GYN Exam (1/year)	100%	70% covered after deductible	100%	60% covered after deductible	100%	100% covered after deductible	100% covered after co-pay
Well Child Care (Routine Physical Exam - Child)	100% Child: First 12 months of life: 6 exams; 2 to 3 years: 2 exams; 4-15 years: 1 exam/calendar year	70% covered after deductible	100% Child: First 12 months of life: 6 exams; 2 to 3 years: 2 exams; 4-15 years: 1 exam/calendar year	60% covered after deductible	100% Child: First 12 months of life: 6 exams; 2 to 3 years: 2 exams; 4-15 years: 1 exam/calendar year	100% covered after deductible	100% covered after co-pay
Immunizations	100%	70% covered after deductible	100%	60% covered after deductible	100%	100% covered after deductible	100% covered after co-pay
Short Term Rehab Visits	$35 co-pay (60 visit limit)	70% covered after deductible (60 visit limit)	$35 co-pay (60 visit limit)	60% covered after deductible (60 visit limit)	100% covered after deductible (60 visit limit)	100% covered after deductible (60 visit limit)	$35 co-pay
Diagnostic Radiology and Laboratory Services	90% covered after deductible	70% covered after deductible	80% covered after deductible	60% covered after deductible	100% covered after deductible	100% covered after deductible	100% covered
Chiropractic Care	$35 co-pay (20 visit limit)	70% covered after deductible (20 visit limit)	50% covered after deductible (20 visit limit)	50% covered after deductible (20 visit limit)	100% covered after deductible (20 visit limit)	100% covered after deductible (20 visit limit)	$35 co-pay (20 visit limit)
Hospital
Inpatient Hospital Admissions - Facility Charge	90% covered after deductible	70% covered after deductible	80% covered after deductible	60% covered after deductible	100% covered after deductible	100% covered after deductible	100% covered after $300 co-pay
Associated Professional Services	90% after the deductible	70% covered after deductible	80% covered after deductible	60% covered after deductible	100% covered after deductible	100% covered after deductible	N/A
Outpatient Surgery	90% covered after deductible, $35 in office	70% covered after deductible	80% covered after deductible	60% covered after deductible	100% covered after deductible	100% covered after deductible	$125 co-pay
Emergency Care
Life Threatening	100% after $100 co-pay (waived if admitted immediately)	100% after $100 co-pay (waived if admitted immediately)	80% covered, waive deductible	80% covered, waive deductible	100% covered, waive deductible	100% covered, waive deductible	Emergency Only - 100% $100 co-pay
Non-emergency use of Emergency Room	50% covered after deductible	50% covered after deductible	50% covered after deductible	50% covered after deductible	50% covered after deductible	50% covered after deductible	Not covered
Prescription Drugs*
Retail-30 day supply	Generic: $10 co-pay Formulary: 20% co-insurance ($25 min to $45 max) Non-Formulary: 30% co-insurance ($45 min to $65 max)	In-Network Benefit Only	Generic: $10 co-pay Formulary: 20% co-insurance ($25 min to $45 max) Non-Formulary: 30% co-insurance ($45 min to $65 max)	In-Network Benefit Only	100% covered after deductible	In-Network Benefit Only	Generic: $10 co-pay Formulary: 20% co-insurance ($25 min to $45 max) Non-Formulary: 30% co-insurance ($45 min to $65 max)
Mail Order-90 day supply	Generic: $20 co-pay Formulary: 20% co-insurance ($50 min to $90 max) Non-Formulary: 30% co-insurance ($90 min to $130 max)	In-Network Benefit Only	Generic: $20 co-pay Formulary: 20% co-insurance ($50 min to $90 max) Non-Formulary: 30% co-insurance ($90 min to $130 max)	In-Network Benefit Only	100% covered after deductible	In-Network Benefit Only	Generic: $20 co-pay Formulary: 20% co-insurance ($50 min to $90 max) Non-Formulary: 30% co-insurance ($90 min to $130 max)
Additional Services	Oral & Injectable Contraceptives-covered; Smoking Cessation Drugs-covered; Weight Loss Drugs-not covered; Impotency Drugs-covered, limited to 8 pills per month at retail and not covered under mail order; Infertility Drugs-not covered	In-Network Benefit Only	Oral & Injectable Contraceptives-covered; Smoking Cessation Drugs-covered; Weight Loss Drugs-not covered; Impotency Drugs-covered, limited to 8 pills per month at retail and not covered under mail order; Infertility Drugs-not covered	In-Network Benefit Only	Oral & Injectable Contraceptives-covered; Smoking Cessation Drugs-covered; Weight Loss Drugs-not covered; Impotency Drugs-covered, limited to 8 pills per month at retail and not covered under mail order; Infertility Drugs-not covered	In-Network Benefit Only	Oral & Injectable Contraceptives-covered; Smoking Cessation Drugs-covered; Weight Loss Drugs-not covered; Impotency Drugs-covered, limited to 8 pills per month at retail and not covered under mail order; Infertility Drugs-not covered
Specialty Mail Order - 30 day Supply	Generic: $7 co-pay Formulary: 20% co-insurance ($17 min to $30 max) Non-Formulary: 30% co-insurance ($30 min to $43 max)	In-Network Benefit Only	Generic: $7 co-pay Formulary: 20% co-insurance ($17 min to $30 max) Non-Formulary: 30% co-insurance ($30 min to $43 max)	In-Network Benefit Only	100% covered after deductible	In-Network Benefit Only	Generic: $7 co-pay Formulary: 20% co-insurance ($17 min to $30 max) Non-Formulary: 30% co-insurance ($30 min to $43 max)
Diabetic Supplies, 90-day supply for Retail or Mail Order	Includes: Needles/Syringes and Insulin; Test Strips; Lancets-20% copay ($25 min to $45 max)	In-Network Benefit Only	Includes: Needles/Syringes and Insulin; Test Strips; Lancets-20% copay ($25 min to $45 max)	In-Network Benefit Only	100% covered after deductible	In-Network Benefit Only	Includes: Needles/Syringes and Insulin; Test Strips; Lancets-20% copay ($25 min to $45 max)
Mental Health and Chemical Dependency Rehabilitation
Outpatient Mental Health Visits	$35 copay, 30 visit max	70% after deductible, 30 visit max	$35 co-pay, 30 visit max	60% after deductible, 30 visit max	100% covered after deductible, 30 visit max	100% after deductible, 30 visit max	$35 co-pay
Inpatient Mental Health - Facility Charge	90% after the deductible, 30 day max	70% after deductible, 30 day max	80% after deductible, 30 day max	60% after deductible, 30 day max	100% covered after deductible, 30 max	100% after deductible, 30 day max	$300 co-pay
Associated Professional Services	90% after the deductible, 30 day max	70% after deductible, 30 day max	80% after deductible, 30 day max	60% after deductible, 30 day max	100% covered after deductible, 30 max	100% after deductible, 30 day max	N/A
Outpatient Chemical Dependency Visits	90% after the deductible, 30 visit max	70% after deductible, 30 visit max	$35 co-pay, 30 visit max	60% after deductible, 30 visit max	100% covered after deductible, 30 visit max	100% after deductible, 30 visit max	$35 co-pay
Inpatient Chemical Dependency- Facility Charge	90% after the deductible, 30 day max	70% after deductible, 30 day max	80% after deductible, 30 day max	60% after deductible, 30 day max	100% covered after deductible, 30 day max	100% after deductible, 30 day max	$300 co-pay
Associated Professional Services	90% after the deductible, 30 day max	70% after deductible, 30 day max	80% after deductible, 30 day max	60% after deductible, 30 day max	100% covered after deductible, 30 max	100% after deductible, 30 day max	N/A
Health Savings Account (HSA) Company Contribution
Individual	N/A	N/A	N/A	N/A	$500	$500	N/A
Family	N/A	N/A	N/A	N/A	$1,000	$1,000	N/A
Deductibles
Individual	$250	$500	$750	$1,500	$2,000	$4,000	None
Individual + 1	$500	$1,000	$1,500	$3,000	$4,000	$8,000	None
Family	$750	$1,500	$2,250	$4,500	$4,000	$8,000	None
Co-Insurance Maximum
Individual	$1,000	$1,500	$2,000	$3,000	$2,000	$4,000	None
Individual + 1	$2,000	$3,000	$4,000	$6,000	$4,000	$8,000	None
Family	$3,000	$4,500	$6,000	$9,000	$4,000	$8,000	None
Other Information
Lifetime Maximum	$2 million for all Plans (combined)						Unlimited
Member Services Phone Number	1-866-262-1180						See Contacts and Links
Web site address	www.hcbo.com						See Contacts and Links

** IMPORTANT NOTE: The Cigna CT HMO plan is subject to variable state and local insurance plan filings. For specific plan provisions, contact your HMO carrier directly for detailed information.

Important Legal Information: This site is designed to provide easy-to-understand explanations of the key features of the Valassis benefit plans. These descriptions do not necessarily include all the plan details, which are contained in the official plan documents. In the event of any contradiction between the information in these Summary Plan Descriptions and the official plan documents, the official plan documents will govern in all cases. More information...